Obstetrics - Abnormal pregnancy Flashcards
One of the strongest risk factors for ectopic pregnancy is
prior ectopic pregnancy
- On laboratory studies, the classic finding is a β-hCG level that is low for gestational age and does not increase at the expected rate
Patients who present with an unruptured ectopic pregnancy can be treated
surgically or medically.
MTX for medical, uncomplicated, nonthreatening ectopics
1st trimester spontaneous abortion
most are 2/2 abnormal chromosomes, of which 95% are due to errors in maternal gametogenesis.
A patient with a threatened abortion should be followed for continued bleeding and placed on pelvic rest with nothing per vagina. Often, the bleeding will resolve. However, these patients are at increased risk for preterm labor (PTL) and preterm premature rupture of membranes (PPROM).
All Rh-negative pregnant women who experience
vaginal bleeding during pregnancy should receive RhoGAM to prevent isoimmunization
2nd trimester spontaneous abortion
Infection, maternal uterine or cervical anatomic defects, maternal systemic disease, exposure to fetotoxic agents, and trauma are all associated with late abortions.
Cervical incompetence is estimated to cause approximately 15% of all second-trimester losses
- place cerclage at 12 wks —> 38 weeks take out
Recurrent pregnancy loss - what do you think of?
chromosomal abnormalities,
maternal systemic disease,
maternal anatomic defects,
infection.
Workup:
- antiphospholipid antibody (APA) syndrome.
- luteal phase defect —> lack an adequate level
of progesterone to maintain the pregnancy
Genetics question - 2 aa spouses, no SCD. Husband’s brother has sickle cell. Carrier rate in aa is 1/10.
What are chance baby has SCD?
Sickle cell anemia is an autosomal recessive condition that occurs in 1/500 births in the African-American population. The carrier state, or sickle-cell trait, is found in approximately 1/10 African-Americans. Since the patient’s brother is affected, both of their parents have to be carriers. Each time two carrier parents for an autosomal recessive condition conceive there is a 1/4 chance of having either an affected or an unaffected child and a 1/2 chance of having a child who is a carrier. Since the patient is unaffected, she has a 1/3 chance of not being a carrier and a 2/3 chance of being a carrier. The patient’s husband has a 1/10 chance of being a carrier (the general population risk for African-Americans). Thus, the chance that this couple will have a child with sickle cell anemia is: 2/3 X 1/10 X 1/4 = 1/60.
A spontaneous abortion (SAB), or miscarriage, is
a pregnancy that ends before 20 weeks’ gestation.
Complete abortion
complete expulsion of all POC before 20 weeks’
gestation
Cervix closes after expulsion
Associated pain and uterine contractions stop
US = empty uterus
Incomplete abortion
- what is it
- clinical sx
- cervix
- US
- tx
partial expulsion of some but not all POC before 20 weeks’ gestation.
Clinical sx
- vaginal bleeding w/ passage of large clots or tissue
- uterine cramps
- products of conception often visualized in dilated cervical os
Os - OPEN
US = some fetal tissue, products of conception often in cervix
Tx
- D&C or expectant management or med management (prostaglandins)
Inevitable abortion
- what is it
- clinical sx
- cervix
- US
- tx
+/- expulsion of products, but vaginal bleeding and dilation of the cervix such that a viable pregnancy is unlikely.
Clinical sx
- vaginal bleeding
- uterine cramps
- possible intrauterine fetus w/ heartbeat
- May be able to see products of conception through dilated cervix
Os - OPEN
US = ruptured or collapsed gestational sac +/- fetal heartbeat
***Same presentation as missed ab but it is INCOMPLETE (vs no) evacuation of conceptus and will have lower abdominal cramps
Tx
- D&C or expectant mangement or med management (prostaglandins)
Threatened abortion
- what is it
- clinical sx
- cervix
- us
- Tx
Vaginal bleeding before 20 weeks without the passage of any products.
Clinical sx
- variable amt vaginal bleeding
- pregnancy can go to viable birth
OS - CLOSED
US - Fetus alive, + FHR
Tx - reassure and outpatient followup
Missed abortion
- what is it
- clinical sx
- cervix
- US
- Tx
death of the embryo or fetus before 20 weeks with
complete retention of all POC
Clinical signs
- no sx - light vaginal bleeding
- pregnancy sx may decrease
- Suspect when STOP N/V of early pregnancy and arrest of uterine growth
Os - CLOSED
US - ruptured or collapsed gestational sac with no fetal cardiac activity
Tx
- D&C, expectant manage, med manage (prostaglandins)
IUGR in gest diabetes vs prediabetes?
What things are seen in each?
IUGR in pregestational DM, not GDM
Small babies –> type 1 or pregestational
Macrosomiic babies –> GDM
- Risks: Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes
Major causes of antepartum hemorrhage
Placenta previa**
Plactental abruption**
Uterine rupture
Fetal vessel rupture
Placenta previa
abnormal implantation over internal cervical os
Can be complicated by placenta accreta
accounts for 20% antepartum hemorrhage
Happens in 0.5% preggers
Need to do c/s
- if term, do scheduled
- if 36 weeks –> amnio to assess lung maturity
Vasa previa
Velamentous cord insertion causes fetal vessels to pass over internal cervical os
fetal blood vessels cross fetal membranes in lower segment of uterus between fetus adn internal cervical os
Painless antepartum hemorrhage
rapid deterioration of fetal heart tracing as hemorrhage is fetal origin
Succenturiate lobe
If placenta grows over cervix, which is less well vascularized, can atrophy incompletely causing a placental lobe discrete from teh rest of the placenta
Bleeding from a placenta previa results from
small disruptions in the placental attachment during normal development and thinning of the lower uterine segment during the third trimester
This bleeding may stimulate further uterine contractions,
which in turn stimulates further placental separation and
bleeding.
Placenta accreta
Superficial attachment of placenta uterine myometrium
Placenta can’t separate from uterine wall after delivery of fetus –> hemorrhage and shock
Placenta increta
plcenta invades myometrium
Placenta percreta
Placenta invades through myometrium to uterine serosa
May invade other organs
Increased risk for placenta previa in
Prior uterine surgery (myometcomy, c/s)
Uterine anomalies
Multiple gestations
Multiparity
Advanced maternal age
Smoking
Prev placenta previa
Presentation of placenta previa
Painless vaginal bleeding
DO NOT DO A VAGINAL EXAM! May injure placenta –> hemorrhage
Velamentous placenta
Blood vessels insert between amnion and chorion, away from margin of placenta, leaving vessels largely unprotected and vulnerable to compression or injury
How should you dx placenta previa?
With transvaginal US
- is safe!
Placenta abruption
Premature separation of normally implanted placenta from uterine wall –> hemorrhage between uterine wall and placenta
Predisposing and precipitating factors for placental abruption
predisposing
- HTN
- prev placental abruption
- advanted maternal age
- polyhydramnios
- DM
- vascular insufficiency
- cocaine, meth, cigs, etoh
Precipitating
- trauma
- ROM with polyhydramnios
- PPROM
Presentation of placental abruption
3rd trimester vaginal bleeding
- severe abdominal pain
- strong ctx
Firm, tender uterus
Couvelaire uterus
- only seen at time of c/s
- blood from abruption infiltrates myometrium –> seorsa and gives bluish purple tone that can be seen on surface of uterus
Can try to dx previa vs abruption via US (always do) but not seeing one does not rule it out
Hypovolemic shock
Consumptive coagulopathy
Risk factors for uterine rupture
prior uterine surgery/scar
Lots of oxytocin
Multiparity
Uterine distention
Large fetus
Trauma
S/p repair of uterine rupture - what do you do for future pregnancies?
Try to tell them not to get pregnant!
If they do, repeat c/s at 36 weeks after confirm fetal lung matruity or at 37 weeks without testing for fetal lung matuirty
Fetal vessel rupture
Mostly 2/2 velamentous cord insertion
Can cause vasa previa or succenturiate lobes
Dx with US
Present w/ vaginal bleeding + sinusoidal FHR pattern –> immediate c/s!
Apt test
Can be used during time of vaginal bleeding
Examine blood for nucleated (fetal) RBCs
If mix is pink = fetal blood
Yellow brown = maternal blood
Sinusoidal pattern on FHR monitoring =
fetal anemia
Variable decelerations
Cord compression/prolapse
Oligohydramnios
Late decelerations
Uteroplatental insufficiency
SGA can be divided in
Decreased growth potential
IUGR
Decreased growth potential reasons
Congenital abnormalities
Teratogens
- EtOH
- cigs
Infxn
- CMV
- rubella
Anytime a fundal height is ____ less than expected, fetal growth should be estimated via ________
3 cm
ultrasound
Suspect IUGR
Normal flow through the umbilical artery is higher during
systole
The flow during diastole should never be absent
However, in the setting of increased placental resistance, which can be seen with a thrombosed or calcifed placenta, diastolic fl ow decreases or even becomes
absent or reversed. Reversed diastolic flow is particularly
concerning and is associated with a high risk of intrauterine fetal demise.
Macrosomia vs LGA
LGA = EFW > 90th percentile
Macrosomia = BW > 4500 in non-diabetic or BW > 4000 in diabetic
Risk factors for macrosomia
Diabetes Obesity Postterm preggers Previous LGA or macrosomia Maternal stature Multiparity Male infant Beckwith-Wiedemann syndrome
oligohydramnios
- def
- causes
1 cause of oligohydramnios = ROM
AFI < 5 by S
Decreased production or increased withdrawl
Chronic uteroplacental insufficiency (fetus doesn’t have nutrients or blood volume to maintain adequate GFR)
GU anomalies (potter syndrome, PCKD, obstruction)
Tx oligohydramnios
Depends on underlying etiology
Labor if
- term
- ROM
If GU anomalies
- MFM consult
Amnioinfusion
Polyhydramnios
- def
- causes
AFI > 20 or 25
NOT good!
Diabetes
Hydrops 2/2 high output cardiac failure
Multiple gestation
TE fistula, duodenal atresia
Erythroblastosis fetalis
In sensitized Rh- mother who has a Rh+ baby
Hyperdynamic state Heart failure Diffuse edema Ascites Pericardial effusion
How to tx unsensitized Rh- mom?
RhoGAM should be administered at 28 weeks and postpartum if the neonate is Rh positive
Tx sensitized Rh - mom
Follow antibody titers q 4 weeks
If baby Rh +, screen fetal anemia with MCA doppler measurements (increased peak systolic velocity measurements = concern for anemia)
Can also use serial amniocentesis, but usually use MCA doppler. Use amniocentesis if questionable results
Retained intrauterine fetal demise (IUFD) > 3-4 weeks can lead to
Hypofibrinogenemia —> DIC!
Make sure you evacuate the baby or deliver!
Postterm pregnancy
> 42 wks GA
or
> 294 days past LMP
Twin twin transfusion syndrome
2/2 unequal flow within vascular communications between twins in their shared placenta!
One twin will become donor, the other recipient
- donor will become anemic, IUGR, oligohydramnios
- recipient will be polyhydramnios, and may lead to heart failure and hydrops
Risk in Mono-Di twins
Examine US q 2 weeks to make sure amniotic fluid is equal
Tx
- serial amnio reduction
- coagulating vessels causing TTS
Risks with Mo-mo twins
Cord entaglement
Intrauterine fetal death
Usually deliver with c/s
Dx appendicitis in pregnancy
clinical findings and graded compression ultrasonography that is sensitive and specific especially before 35 weeks gestation
Macrosomic neonates are most at risk for
neonatal jaundice, hypoglycemia, birth trauma, hypocalcemia, childhood cancers such as leukemia, osteosarcoma, or Wilms tumor
When do you perform NSTs?
NSTs are generally not indicated in a routine pregnancy
until the pregnancy goes into the 41st week
Use in high risk starting at 32-34 weeks GA or when decrease in fetal mvmts in any pregnancy
Reactive
- 2 fetal HR accels / 20 mins
- repeat weekly
Nonreactive
- most common reason is sleeping baby –> use vibroacoustic stimulation to wake up baby
If still not reactive with vibroacoustic stim –> BPP use
Preeclampsia - pathogenesis
Dx by presence of
- nondependent edema (no longer components of dx)
- HTN
- Proteinuria
Pathophys
- generalized arteriolar constriction (vasospasm)
- intravascular depeltion 2/2 generalized transudative edema
- produces sx related to ischemia, necrosis, hemorrage of organs
HELLP syndrome
Subcategory of preeclampsia
Hemolysis
- schistocytes
- LDH elevation
- elevated bilirubin
Elevated LFTs
Low Platelets
Very serious!
More likely to be < 36 wks gestation
Warning signs: RUQ pain Epigastric pain N/V esp in 3rd trimester!
If see HTN early in second trimester, what do you consider?
Hydatidiform mole
Prev undiagnosed chronic HTN
Risk factors for preeclampsia
Chronic HTN Chronic renal dz Collagen vascular disease African american Maternal age (v young or v old)
Nulliparity
Prev preeclampsia
Multiple gestation
Abnormal placentation
Mother in law
Cohabitation < 1 y
Fetal complications of preeclampsia
Acute Uteroplacental insufficiency
- placental infarct and/or abruption
- intrapartum fetal distress
- still birth
Chronic uteroplacental insufficiency
- SGA fetuses
- IUGR
Oligohydramnios
Increased premmies
Increased c/s
Maternal complications of preeclampsia
Seizure Cerebral hemorrhage DIC Renal failure Hepatic failure
Pulm edema**
- endothelial damage –> increased vascular permeability
- decreased albumin
- decreased renal function
- arterial vasospasm –> increased vascular R –> decreased CO with CHF
Crtieria to dx Gestational HTN
SBP > 140 or DBP > 90
- should have BP elevated at least 2x 4-6 hrs apart, taken while seated
Criteria to dx mild preeclampsia
SBP > 140 or DBP > 90
- 2x taken 4-6 hrs apart
Proteinuria
> 300 mg/24h
or
1-2+ on dipstick
Criteria to dx severe preeclampsia
SBP > 160 or DBP > 110
OR signs/sx of severe preeclampsia
HA Visual changes, scotoma Pulm edema Acute renal failure Oliguria Proteinuria RUQ pain LFT elevation Hemolytic anemia Thrombocytopenia DIC IUGR, abnl umbilical dopplers
Criteria to dx Eclapmsia
Seizure! - grandmal
Complications:
- cerebral hemorrhage
- aspiration pna
- hypoxic encephalopathy
- thromboembolic events
Acute fatty liver of pregnancy
vs HELLP, lab tests below are associated wtih AFLP:
- elevated NH4
- blood glucose < 50
- reduced fibrinogen adn antithrombin III
Tx mild preeclampsia
Induction of labor:
- term
- unstable preterm
- fetal lung maturity present
C/s for ob indication
IV hydralazine or labetalol for BP
Betamethasone for fetal lung matuity
MgSO4 for seizure ppx
Tx severe preeclampsia
Goals
- prevent eclampsia
- control maternal BP
- deliver fetus
+ MgSO4, hydralazine or labetalol
Betamethasone if 24-32 weeks
> 32 weeks, deliver immediately!
Continue seizure ppx 24 hrs postpartum
Contraindications to expectant management:
- thrombocytopenia < 100,000
- inability to control blood pressure with maximum doses of 2 antihypertensive medications,
- non-reassuring fetal surveillance,
- liver function test > 2x normal,
- eclampsia,
- persistent CNS (central nervous system) symptoms
- oliguria.
Delivery should not be based on the degree of proteinuria.
Tx ecclampsia
Seizure management
- MgSO4
BP control
- hydralazine
Ppx for convulsions
- MgSO4 (continue until 12-24 hrs after delivery)
Deliver baby when mother stabilized
What do you do if MgSO4 OD?
CaCl or Ca gluconate for cardiac protection
Therapeutic: 4-7 mEq/L
Lose DTR: 7-10
Resp depression: 11
Cardiac arrest: 15
Pulmonary edema can occur with magnesium therapy, but is not related to toxicity from the drug.
Most common anti-HTN used in preggers?
Labetalol
NIfedipine
Superimposed preeclampsia on chronic HTN….how to dx?
increase in SBP of 30
When do most eclamptic seizures happen?
during labor
How do you get increased insulin resistance and generalized carb intolerance in preggers?
Human placental lactogen (and others) act as anti insulin agents
Gestational vs pregestational diabetes risks on fetus
GDM not at risk for congenital anomalies as much as pregestational diabetes
Macrosomia in GDM vs. IUGR in pregestational diabetes 2/2 uteroplacental insufficiency
But both have risk of
macrosomia
birth injuries
neonatal hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia
As a result of the increased glucose load, the fetus secretes more insulin. As a growth factor, increased insulin levels result in increased fetal growth. I
This central deposition of fat is characteristic of diabetic macrosomia and underlies the dangers associated with vaginal delivery in these pregnancies.
Best time to screen for gestational diabetes
24-28 weeks (second trimester)
Screening test for GDM
Give 50g glucose —> measure plasma glucose 1 hr later
- if > 130-140 glucose, —-> + and may need glucose tolerance test
Glucose tolerance test
Dx GDM
- 3 day special carb diet, 8 hr fast, then give 100g glucose - eval at 1, 2, 3, hrs after load
- if 2 or more have elevated sugars, GDM is +
Tx for GDM
Initially start with diet + exercise
If that fails to control sugars, give insulin
- can also give glyburide or metformin
Dx with GDM, what do you do for prenatal care?
NST or BPP starting at 32 and 36 weeks gestation
- q weekly until delivery
Est fetal wt US between 34-38 weeks
Oligo vs polyhydraminos if diabetes + preggers?
polyhydraminos
For pregestational diabetics, when do you start eval growth and well being of fetus with screen?
32 weeks
weekly NSTs until 36 weeks
US to assess fetal growth between 32-36 weeks GA
Offer induction of labor at 39 weeks
Risks of Bacterial vaginosis in pregnancy
PPROM Preterm delivery puerperal infection (chorioamnionitis, endometritis)
However, you DO NOT routinely screen for BV in asymptomatic women
You DO tx those with sx and infected during pregnancy
Dx BV
Tx BV
(1) presence of thin, white or gray, homogeneous discharge coating the vaginal walls;
(2) an amine (or “fishy”) odor noted with addition of 10% KOH (“whiff” test);
(3) pH of greater than 4.5;
(4) presence of more than 20% of the epithelial cells as “clue cells” (squamous epithelial cells so heavily stippled with bacteria that their borders are obscured) on microscopic examination.
Tx
- Metromidazole x1wk (better)
- Clinda x1wk
Chorioamnionitis
- what is it
- dx
- tx
1 precursor of neonatal sepsis
Infection of membranes and amniotic fluid surrounding fetus
Assoc w/ preterm + prolonged ROM
Usually polymicrobial infxn of rectum and vagina
Dx: - maternal fever - elevated WBC - uterine tenderness - maternal tachy/fetal tachy - foul smelling amniotic fluid HIGH INDEX OF SUSPICION! ---> gold standard dx = cx of amniotic fluid
Elevated IL6 level in amniotic fluid is most sensitive adn specific marker for predicting + amniotic fluid cx
Tx
- IV abx –> 2nd or 3rd gen cephalosporin or amp + gent
- delivery
Which HSV is mostly genital?
HSV 2
It pt has herpes, do you need c/s
Only if there are active lesions
Do a thorough check!
Can you use acyclovir or valacyclovir during preggers?
Yes!
Neonatal herpes
Disseminated
CNS disease
Disease of skin, eyes or mouth
Viral sepsis
PNA
Herpes encephalitis
Tx acyclovir IV
Congenital varicella syndrome
Transplacental vertical transmission!
Skin scarring
Limb hypoplasia
Chorioretinitis
Microcephaly
Neonatal VZV infection high mortality when..
maternal dz develops from 5 days before delivery up to 48 hours postpartum
Susceptible preggers exposed to varicella person…what do you do?
Tx within 72-96 hrs with 1 of the 2:
- VZV Immune - globulin but does not prevent transmission to fetus
- oral acyclovir or valacyclovir
Parvovirus infection - effects on baby
First-trimester infections have been associated with miscarriage,
midtrimester and later infections are associated with fetal hydrops - 2/2 RBC aplasia
if studies indicate an acute parvovirus infection (positive IgM and positive or negative IgG) beyond 20 weeks
of gestation, then the fetus should undergo serial ultrasounds, up to 8 to 10 weeks after maternal infection is suspected to have occurred.
- also use MCA dopper to estimate fetal anemia
The most sensitive and specific test for diagnosing congenital CMV infection is
the identification of CMV in amniotic fluid by either culture or PCR
Identification of the virus in amniotic fluid by culture or PCR does not necessarily indicate the severity
of fetal injury.
The principal sonographic findings suggestive of serious fetal injury are microcephaly, ventriculomegaly, intercerebral calcification, fetal hydrops, growth restriction, oligohydramnios.
CMV infection most serious fetal sequelae occur after maternal CMV infection during
1st trimester
Infants infected after maternal CMV reactivation generally are
asymptomatic at birth.
Congenital hearing loss is typically the most severe sequela of secondary infection
Most common neonatal CMV infection sequelae
- periventricular calcifications*******
- chorioretinitis
- # 1 cause sensorineural hearing loss
- seizures
- IUGR
- hepatosplenomegaly
- microcephaly
Neonatal rubella greatest risk
before 18 weeks gestation
Maternal fetal transmission rate highest during first trimester as are the rates of congenital abnormalities
Most common neonatal rubella infection sequelae
- cataracts*****
- PDA, pulmonary stenosis
- blueberry muffin lesions 2/2 dermal erythropoiesis
- sensorineural hearing loss
MMR vaccine in preggers?
NO!
Because of theoretic risk of transmission of the live virus in the vaccine, patients do not receive the measles, mumps, and rubella (MMR) vaccine until postpartum,
patients are advised to avoid pregnancy for 1 month following vaccination.
All HIV-infected women should be monitored with
(1) viral loads every month until the virus is undetectable and then every 2 to 3 months,
(2) CD4 counts (absolute number or percent) each trimester,
(3) resistance testing if they have recently seroconverted
or if the therapy failed.
Do 3-drug HAART therapy
If mother not on HAART intrapartum, give zidovudine
In HIV + women, c/s delivery recommended in those
Whose viral copies > 1,000
in women with viral loads of less than 1,000 copies/mL, there does not appear to be any additional benefit of cesarean delivery versus vaginal delivery in HIV perinatal transmission
Amniotic infection syndrome w/ gonorrhea
Placental fetal membrane
Umbilical cord inflammation occuring after PROM
Assoc w/ infected oral adn gastric aspirate, leukocytosis, neonatal infection, maternal fever
Tx maternal gonorrhea
IM ceftriaxone
Oral Cefixime
IM spectinomycin
Azithro or amox for concurrent chlamydia infection
Tx maternal chlamydia
Azithromycin
Amoxicillin
Erythromycin
Neonates delivered to seropositive Hep B mothers should receive
hepatitis B immune globulin within 12 hours
after birth.
Before their discharge from the hospital, these infants
also should begin the hepatitis B vaccination series.
recommends universal vaccination of all infants for hepatitis B
while T. pallidum can cross the placenta and infect the fetus as early as 6 weeks’ gestations, clinical manifestations are not apparent until
after 16 weeks of gestation when fetal immunocompetence develops
Syphilis during pregnancy that results in vertical transmission may lead to
a late abortion, intrauterine fetal demise, hydrops, preterm delivery, neonatal death, early congenital syphilis, and the classic stigmata of late congenital syphilis
Neonates with early congenital syphilis (onset at younger than 2 years of age) present with a
systemic illness accompanied by a maculopapular rash, snuffles, hepatomegaly, splenomegaly, hemolysis, lymphadenopathy, jaundice, pseudoparalysis of Parrot due to osteochondritis, chorioretinitis, and iritis.
Diagnosis of congenital syphilis can be made by ID of IgM antitreponemal antibodies, which do not cross the placenta.
Late congenital syphilis: saber shins, mulberry molars Hutchinson’s teeth, saddle nose, eighth nerve deafness, mental retardation, hydrocephalus, optic nerve atrophy, and Clutton joints
Tx syphillis
PCN ONLY!
desensitize those allergic
Vertical transmission of Toxo more common when disease acquired in
3rd trimester
If get in 1st trimester, less likely to transmit but causes worse consequences
Neonatal toxo
- intracranial calcifications***
- chorioretinits
- hydrocephalus 2/2 aqueductal stenosis
Tx maternal toxo infection
Spiramycin
- doesn’t cross placenta so can’t help baby
Pyrimethamine + sulfadiazine for documented fetal infection
- do not use pyrimethamine during first trimester
- give with folic acid
For baby, tx for 1 year with pyrimethamine, sulfadiazine, leucovorin
Pyelonephritis has significant morbidity during pregnancy
and is associated with high rates of
ICU admission and ARDS.
When start HAART for HIV in preggers?
3 drug regimen
Start in 2nd trimester - goal is viral suppression by third semester
hyperemesis gravidarum
persistent vomiting,
weight loss of greater than 5% of prepregnancy body weight,
ketonuria.
hyperemesis is common in the setting of molar pregnancies (likely since HCG levels can be very high)
Sx start between 4-10 weeks adn stop by week 20
If sx start after week 10 or do not stop by week 20, think of another etiology (molar, gastro, pyelo, etc)
Tx hyperemesis gravidarum
Promethazine +/- Metoclopramide, ondansetron, droperidol
vitamin B6 and doxylamine
Estrogen and progesterone both increase in preggers- does this help seizure
Estrogen increases seizures!
Progesterone decreases seizures
Antiepileptics better in preggers
Levetiracetam Lamotrigine Felbamate Topiramate Oxcarbamazepine
Management of epileptic preggers
Always do Level II study though on women taking AEDs at 19 and 20 weeks gestation
Amnio for AFP and acetylcholinesterase
Supplement with oral Vitamin K until delivery (optional)
Start on folate
What common cardiac/heme drugs need to be d/c before preggers?
ACEi
Diuretics
Warfarin
For preggers with eisenmenger or pulm HTN, what do you do for delivery of child?
Labor and assisted vaginal delivery better than elective c/s
Peripartum cardiomyopathy
Patients with PPCM should be managed according to
the GA of the fetus.
> 34 wks - better to deliver as risk for remaining preggers are greater than premie baby
At earlier GA
- betamethasone for fetal lung matuirty
- patient delivered accordingly
Meds:
- diuretics
- digoxin
- vasodilators.
Most return to baseline cardiac delivery several months after delivery
Chronic renal disease and preggers
Increased risk of
- preeclampsia,
- preterm delivery,
- IUGR
should be screened at least once per trimester with a 24-hour urine for creatinine clearance and protein
In pregnancy, the production of clotting factors
is increased except for II, V and IX.
increased levels of fibrinopeptide A, which is cleaved from fibrinogen to make fibrin
Tx DVT in preggers
Enoxaparin (LMWH)
or
Unfractionated heparin
Warfarin on baby
nasal hypoplasia and skeletal abnormalities
CNS defects
Optic atrophy
Dx PE in preggers
Spiral CT
Health of mom is more important!
Tx hyperthyroidism in preggers
Usually 2/2 graves
Get thyroid stimulating immunoglobulins at beg of preggers
Tx:
PTU or methimazole
- low doses as can cross placenta and lead to fetal goiter
Antenatal testing with serial NSTs
- risk of fetal hyperthyroidism, which can be diagnosed with fetal tachycardia.
Tx hypothyroidism in preggers
Usually 2/2 hashimoto’s
Increase levothyroixine 25-30% as increased demand for TH 2/2 increased binding of TH, increased basal metabolic rate, etc
SLE prognosis in pregnancy
1/3 get better, 1/3 stay same, 1/3 get worse
In general, it also seems that patients who are without flares immediately prior to pregnancy have a better
course.
Meds:
- continue ASA, steroids
- D/C cyclophosphamide and MTX
Early pregnancy issues with SLE/collagen vascular diseases
Early preggers loss
2nd trimester loss common
Asymmetrical IUGR
SLE vs. preeclampsia
SLE flare will have reduced C3 and C4, whereas patients
with preeclampsia should have normal levels.
SLE flares are often accompanied by active urine sediment, whereas preeclampsia is not.
Tx SLE flare in preggers
Steroids
If doesn’t respond, cyclophosphamide
vs. preeclampsia tx w/ delivery
Irreversible effect of neonatal lupus
Congenital heart block
anti-Ro (SSA) and anti-La (SSB) damage fetal cardiac conduction system, specifically AV node
- anti Ro more likely to cause heart block
Tx EtOH WD in preggers
Barbituates
Benzos are teratogenic!
Effects of smoking on preggers/baby
spontaneous abortions,
preterm births,
abruptio placentae,
decreased birth weight
Increased risk of SIDS
Cocaine use in pregnancy is correlated with
abruptio placentae,
IUGR,
an increased risk for preterm labor and delivery.
The most common narcotics used in pregnancy are
oxycodone,
heroin,
methadone
Narcotic use in pregnancy
No teratogenic effects of narcotics!
Risks of opiod withdrawal include
- miscarriage,
- preterm delivery,
- fetal death.
Enroll preggers in methadone programs rather than advised to quit outright.
Also can use buprenorphine (Suboxone)
Caffeine use in preggers
Caffeine use greater than 150 mg/day has been correlated with an increased risk of spontaneous abortions
Ab pain + bleeding + suspected ectopic but hemodynamically stable
What do you do?
How do you dx?
Tx?
Repeat bHCG in 48 hrs
Dx (with 1 of the following):
1) a fetal pole is visualized outside the uterus on ultrasound;
2) the patient has a b-hCG level over the discriminatory zone (1500-2000) and there is no IUP on ultrasound;
3) Pt’s b-hCG level rises less than 50% in 48 hrs or levels which do not fall following diagnostic dilation and curettage.
Tx w/ MTX if remain stable
When is it ok to use MTX for ectopic?
hemodynamic stability,
nonruptured ectopic pregnancy,
size of ectopic mass <3.5 cm in the presence of a fetal heart rate,
normal liver enzymes and renal function,
normal white cell count,
the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes
Diseases assoc with early pregnancy loss
diabetes mellitus,
chronic renal disease
lupus
thyroid disease
Renal infection is the most common serious medical complication of pregnancy.
What do you do for this?
IV hydration
Abx
If not afebrile/clinical improvement by 72 hrs, US to look for dilatation or calculi or obstruction
Tx Obstruction
- double-J ureteral stent
- long-term stenting –> percutaneous nephrostomy
SSRIs ok for pregnancy
Paroxetine (Paxil) has recently been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension.
The older SSRI compounds, fluoxetine and sertraline, have not been reported to cause early pregnancy loss or birth defects in animals or in humans.
pruritus gravidarum
a common pregnancy-related skin condition that is a mild variant of intrahepatic cholestasis of pregnancy.
retention of bile salt –> deposited in the dermis –> pruritus.
Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels.
Another agent reported to relieve the itching is the opioid antagonist naltrexon.
Dx appendicitis in pregnancy
clinical findings
graded compression ultrasonography that is sensitive and specific especially before 35 weeks gestation
When and how much RhoGam do you give for Rh neg mom?
28 weeks gestation + within 72 hours of delivering an Rh-positive baby
30 cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells
IUFD of 1 twin….what are maternal signs?
Fibrinogen levels may decrease, leading to a coagulopathy in mom (nosebleed, etc)
fibrinogen levels should be monitored to detect a progressive coagulopathy weekly or biweekly
Spalding sign
is an overlapping of fetal skull bones suggesting a fetal demise
systolic/diastolic (S/D) ratio of the umbilical artery is determined by
Doppler ultrasound.
An increase in the S/D ratio reflects increased vascular resistance. It is a common finding in IUGR fetuses.
A normal S/D ratio indicates fetal well-being
a postterm pregnancy is a pregnancy that has progressed past
42 completed weeks
Postterm pregnancies are associated with
placental sulfatase deficiency,
fetal adrenal hypoplasia,
anencephaly,
inaccurate or unknown dates and extrauterine pregnancy.
a patient with irregular menses, it is important to obtain an ultrasound prior to
20 weeks to accurately date the pregnancy
Bradycardia is defined as
fetal heart rate less than 110 beats perminute
UTI abx in pregnancy
OK
- nitrofurantoin
- amoxicillin
- Amoxicillin-vlavulanate
- Cephalexin
NOT OK
- tetracyclines
- fluoroquinolones
- TMP/SMX
TMP SMX in preggers
Use with caution in 2nd trimester
NOT ok in
- 1st trimester (interfere w/ folic acid met)
- 3rd trimester (inc risk of kernicterus in newborn)
Red flags for uterine rupture
Abdominal pain
Fetal HR abnormalities
Loss of fetal station (recession of presenting part)
Gestational diabetes
- target blood glucose levels
- tx
Fasting <=120
Tx
- 1st line: diet + exercise
- 2nd line: insulin subq
Visualizing ectopic
Transabdominal for bHCG > 6500
Transvaginal US for seeing intrauterine sac for bHCG 1500-6500
severe vomiting during pregnancy - what do you do first?
quantitative bHCG to r/o molar pregnancy
if bHCG very high —> do US
Ruptured fetal umbilical vessel
Antepartum hemorrhage
Fetal heart changes from tachy —> brady —-> sinusoidal pattern
Maternal vitals stay ok
If suspect, do Apt test (differentiate maternal from fetal blood)
Can be 2/2 vasa previa —> immediate c/s if so!
Down’s quad screen assoc results
vs
Edward quad screen
Down’s:
Increased
- bHCG
- inhibin A
Decreased
- AFP
- estriol
Edward:
Normal
- inhibin A
Low:
- AFP
- estriol
- bHCG (very low!)
If maternal serum a-fetoprotein levels are abnormal in pregnant patient, what is next step?
US to confirm GA, detect structural anomalies, detect multiple gestation, and confirm viable pregnancy
BPP values and management
Indicated in high risk pregnancies
8-10 is normal
- repeat 1x-2x per week for HROB
8 + dec amniotic fluid volume –> delivery should be considered!
6 + no oligohydramnios
- order contraction stress test and deliver if not reassuring
- contraction stress test = + oxytocin to get 3 ctx/10 min and see if fetus has late decels at contraction. If yes –> + —> delivery recommended
- > 37 weeks –> consider delivery
- < 37 weeks –> repeat BPP in 24 hrs and deliver if not improved
6 + oligohydramnios
- > 32 wks GA —-> delivery
- < 32 wks —> daily monitoring
4 + no oligohydramnios
- fetal lungs mature –> delivery
- fetal lungs not mature –> steroids and BPP assessed within 24 hrs
Score < 4
- deliver if fetus > 26 wks GA
Abrupt onset of hypoxia + respiratory failure, DIC after amnio or delivery should raise suspicion for
Amniotic fluid embolism
Respiratory support (intubate) is always first step in management!
Hypertensive disorders of pregnancy
- chronic HTN
- preeclampsia
- preeclampsia w/ severe features
- eclampsia
- chronic HTN w/ superimposed preeclampsia
- gestational HTN
Chronic HTN
- HTN before conception or 20 weeks getation
Preeclampsia
- elevated BP (systolic >=140 and/or disastolic >-90 on 2 readings 4 hrs apart)
- proteinuria
- normal serum Cr
Preeclampsia
- preeclampsia above + end organ damage (eg elevated creatinine/renal insufficiency, thrombocytopenia, impaired LFTs, pulm edema, cerebral or visual sx)
Eclampsia
- preeclampsia + new onset grand mal seizures
Chronic HTN w/ superimposed preeclampsia
- Chronic HTN +
- new onset proteinuria or worsening existing proteinuria after 20 wks GA
- sudden worsening of BP
- develop end organ damage
Gestational HTN
- new onset elevated BP (systolic >=140 and/or diastolic >=90) after 20 weeks GA
- NO PROTEINURIA
Single most prevalent preventable cause of fetal growth restriction in US
Smoking
Role of US in 3rd trimester bleeding
R/o previa
DOES NOT diagnose abruptio placentae - only finds as few as 25% of them, even with vaginal bleeding
Septic abortion
Fever, malaise, signs of sepsis
Foul smelling vag d/c, CMT, uterine tenderness
Rarely occurs after spontaneous AB - usually with induced
OS - OPEN
US - retained products of conception
When do you use oxytocin for ab?
late 2nd or 3rd trimester
NOT usually in 1st
Anti-HTN meds in pregnancy
Safe/First line
- methyldopa
- labetalol
- hydralazine
- nifedipine
2nd line
- thiazides
- clonidine
NOT OK
- ACEi
- aldo blockers
- direct renin inhibitors
- Lasix
- ARBs
When do you only use zidovudine for HIV + women?
Intrapartum if no antiretrovirals around time of delivery and viral loads >1000 copies
If dx in 3rd trimester (after 28 weeks GA)
HAART 3drug is still best to prevent neonatal HIV infection
Fetal hydantoin syndrome
Exposure to anticonvulsants during fetal development (phenytoin and carbamazepine)
Midfacial hypoplasia Microcephaly Cleft lip and palate Digital hypoplasia hirsutism Developmental delay
IUGR - categories
Fetal growth can be divided into two phases:
< 20 wks GA –> growth is mainly hyperplastic (increasing number of cells);
> 20 weeks —> hypertrophic (inc cell size)
Damage < 20 wks —-> symmetric growth restriction
Damage > 20 wks —> asymmetric growth
2/3 of growth restriction is asymmetric and can be identified by increased head-to-abdominal measurements.
What is the most useful parameter for predicting fetal weight by US in suspected IUGR?
Abdominal circumeference
This is affected in both symmetric and asymmetric growth restriction
Asymmetric IUGR causes
2/2 Uteroplacental insufficiency
- usually maternal factors (HTN, preeclampsia, uterine anomalies, SLE, CVD, smoking)
Normal length
Wt below normal
Head normal
Abd small
Better prognosis than symmetrical
Symmetric IUGR causes
Aneuploidy (Pataus, downs, edwards)
Anemia
Maternal substance abuse
Infections (CMV, rubella, toxo)
IUGR management
- delivery @ 36 wks GA with oligohydramnios and abnormal umbilical artery Doppler studies
- prefer induction of labor vs c/s
- delivery at term if reassuring fetal testing including a normal amniotic fluid volume.
IUGR causes
Maternal
- HTN
- anemia
- CRD
- malnutrition
- DM
Placental
- previa
- abruption
- infarction
- multiple gestations
Management of placental abruption
Foley
Large bore IV line
Ensure rapid vaginal delivery
C/s only if obstetric indications for procedure (prior c/s, small pelvis, obstructive lesions in lower genital tract)
or
when rapid deterioration of state of mother or fetus
Breech presentation –> when do you convert to vertex?
37th week and after! not before!
Liver disorders unique to pregnancy
Intrahepatic cholestasis of pregnancy
HELLP
Acute fatty liver of pregnancy
ICP vs HELLP vs AFLP
ICP
- intense pruritus
- High bile acids, LFTs
- dx of exclusion
HELLP
- preeclampsia
- RUQ pain
- N/V
- Hemolysis
- Mod elevated LFTs
- Thrombocytopenia
AFLP
- Rare! In 3rd trimester, can get liver failure!
- Malaise
- RUQ pain
- N/V
- Sequelae of liver failure
- hypoglycemia
- mildly high LFTs
- High bilirubin
- possible DIC
Pseudocyesis
Psych condition
Woman presents w/ nearly all signs and sx of pregnancy
US = nl endometrial stripe and (-) pregnancy test
If Rh - mom, RH+ baby, how do you admin Rhogam?
28 weeks with standard dose
Dose at postpartum - make sure it is correct dose based on factors!
